Head Injury in Children

Tina Kendrick
Clinical Nurse Consultant - Paediatrics

Some Definitions
Newborn

< 28 days

Infant

< 1 year

Child

< 16th birthday (DoH)

Head Injury
Leading cause of mortality & morbidity in children:
Road trauma, falls, bicycle accidents, abuse and
violence

There are no magic bullets that have significantly

changed outcome in the past decade
Outcome still linked to severity of initial insult

Head Injury
Children have increased survival but increased
morbidity as diffuse brain injury prevalent
Often associated with spinal injury but lower
incidence in children
Care is focussed on:
Close observation
prevention & minimisation of secondary injuries
rehabilitation

Secondary Brain Injury

refers to the cascade of

physiological and biochemical
events that occur after primary
injury and worsen outcome

Most Frequently Occurring

Hypocapnia
Hypotension
Acidosis

Associated With Worse

Outcome
Hypocapnia
Hypotension occurred twice as
often in non-survivors
Acidosis
Hypoxia
Hyperglycaemia
Hypothermia* in younger
individuals

Patterns of Head Injury in children

Some differences from adults that
influence patterns include:
Developmental level and age of the child
Anatomic differences of the head
Frequency of inflicted injury in < 2s
Response of the childs brain to trauma

Developmental Considerations
Unwitnessed/unobtainable history of loss
of consciousness
No LOC, especially in < 2s does not
preclude intracranial injury
GCS may not be reliable in young
children; a modified scale should be used
for infants and young children
Parents generally provide most reliable &
trustworthy information

Anatomic Differences
Characteristics of child skull:
Thinner, provides less protection
Depressed skull # more prevalent
Pliability means underlying brain injury +/bleeding in the absence of fracture
Head = 18% of TBSA in infants; 9% in adults
Intracranial and scalp haematomas can
therefore represent significant blood loss

Anatomic Differences
Blunt trauma can be followed rapidly by
acute brain swelling
Can occur despite:
no significant history
No visible abnormality of the head

Children more disposed to developing

oedema higher brain H2O content
This requires close monitoring of fluid
balance

Body Proportions

Inflicted Injury
Have a high index of suspicion where:
History is inconsistent with physical findings
Infants present with serious head injury after
reportedly minor fall
History changes over time
Another child is blamed
A delay in presentation to ED

Most common cause of head injury in

infants

Assessment of Conscious Level

AVPU Assessment Tool
A: Patient is Alert and
Age-appropriate
V: Patient responds to Voice
P: Patient responds to
Painful stimuli
U: Patient is Unresponsive

Five Assessment Parameters

Level of consciousness
Motor function
Respiratory patterns
Cranial nerve response
Vital signs

Vital Signs
Temperature
SpO2

Pulse and ECG

Respirations
Blood pressure
Standard Paediatric Observation Charts
(SPOC) should be used

Limitations of the Glasgow Coma

Scale for Children
Teasdale & Jennet did not report patient
ages in their original work
Recognised early on (late 70s) that the
GCS was limited in assessing children
under 10 years of age
Preverbal children (under 2 years)
particularly challenging

Eye Opening Response

Spontaneously

(4)

To speech

(3)

To pain

(2)

None

(1)

Eye Opening Response

No age-related modification necessary
Best score is 4

Best Verbal Response <4 years

Alert, babbles or coos, words or sentences
to usual ability
(5)
Less than usual ability and/or spontaneous
irritable cry
(4)
Cries inappropriately
(3)
Occasional whimpers/moans
(2)
None
(1)

Best Verbal Response 4-15 years

Orientated and converses

Disorientated and converses
Inappropriate words
Incomprehensible sounds
None

(5)
(4)
(3)
(2)
(1)

Best Motor Response < 4 years

Obeys verbal command or performs normal
spontaneous movements
(6)
Localises pain or withdraws to touch (5)
Withdraws from pain
(4)
Abnormal flexion to pain
(3)
Abnormal extension to pain
(2)
No response to pain
(1)

Best Motor Response 4-15 years

Obeys verbal command

Localises pain
Withdraws from pain
Abnormal flexion to pain
Abnormal extension to pain
No response to pain

(6)
(5)
(4)
(3)
(2)
(1)

Classification
Severity classification is traditionally used
Is GCS-based
Mild head injury (GCS 14 - 15)
Moderate head injury (GCS 9 - 13)
Severe head injury (GCS 3 - 8)

Severity
In children, CHALICE criteria is now being
used for management
A more comprehensive system, using risk
factors (including GCS) to more accurately
detect intracranial injury
Places children into Low, Intermediate or
High risk groups, which determines
management

Low Risk
Consider immediate discharge

Intermediate Risk
Close observations for 4-6 hours post-injury
until GCS is 15 for 2 hours
May go home if GCS 15, asymptomatic,
responsible carers and normal CT
Any child not asymptomatic and
neurologically normal at 6 hours needs
discussion with paediatric expert or
neurosurg

High Risk
These children require urgent imaging,
neurosurgical and Paed ICU consult via
NETS - regarding transfer, CT decisions
CT abnormalities need Neurosurg input
Those with normal CT should still be
observed for 6 hours min, may require
admission

Further Information
Childrens Hospitals websites Fact Sheets for
parents
NSW Institute of Trauma and Injury
Clinical Excellence Commissions Paediatric
Between the Flags
ACCCNs Critical Care Nursing (2012)
DETECT Junior
Frank Shann DRUG DOSES

References
Australian and New Zealand Paediatric Intensive
Care Data Registry Report, 2010
Brady, Cain & Johnston (2012) Justifying referrals
for paediatric CT. MJA 197 (2) p95-98
Guidelines for the Acute Medical Management of
Severe Traumatic Brain Injury in Infants, Children
and Adolescents 2nd Edition January, 2012 Pediatric
Critical Care Medicine

Useful References

Useful References